Diabetes

The Impact of Social Determinants of Health on Diabetic Retinopathy

In this podcast, Risa M. Wolf, MD, discusses the impact of social determinants of health, such as socioeconomic status, geography, and health care access and affordability, on the screening, prevalence, and management of diabetic retinopathy in adults.

Additional Resource:

  • Patel D, Ananthakrishnan A, Lin T, Channa R, Liu TYA, Wolf RM. Social determinants of health and impact on screening, prevalence, and management of diabetic retinopathy in adults: a narrative review. J Clin Med. 2022;11(23):7120. doi:10.3390/jcm11237120

Risa M. Wolf, MD, is a pediatric endocrinologist and associate professor of pediatrics at The Johns Hopkins Hospital/Johns Hopkins Children's Center. (Baltimore, MD).


 

TRANSCRIPTION:

Jessica Bard:

Hello everyone, and welcome to another installment of Podcast360, your go-to resource for medical news and clinical updates. I'm your moderator, Jessica Bard with Consultant360, a multidisciplinary medical information network.

Diabetic retinopathy is a common eye disease and is the leading cause of blindness in working-age adults, according to the Centers for Disease Control and Prevention. Dr. Risa Wolf is here to speak with us today about social determinants of health and diabetic retinopathy.

Dr Risa M. Wolf:

Thank you for inviting me. I'm Risa Wolf. I'm a pediatric endocrinologist and associate professor at the Johns Hopkins Hospital in Baltimore, Maryland. My clinical and research focus is diabetes and diabetes-related outcomes, including diabetic retinopathy, so I'm happy to talk about that today.

Jessica Bard:

Could you please provide us with an overview of your review, social determinants of health, and the impact on screening prevalence and management of diabetic retinopathy in adults?

Dr Risa M. Wolf:

Yes, and although I am a pediatric endocrinologist, diabetic retinopathy is a major complication of diabetes and a leading cause of blindness in working-age adults in the US, and this is something that we still screen for in the pediatric population, which is where the interest comes from in looking at our children who then become young adults and then adults in the workforce. So making sure that we are preventing these complications is also important from the pediatric endocrinologist's perspective.

But in terms of this review, in the US, underserved and minority populations have been disproportionately affected by diabetic retinopathy and other diabetes-related health outcomes. While the racial disparities that exist here have been well described, we really wanted to delve deeper and also analyze the existing literature on the disparities associated with social determinants of health. So in this review, we discuss how socioeconomic status related to insurance coverage and income, household income, geography, whether you're urban or rural, what kind of neighborhood environment you live in, how healthcare access impacts your outcomes as well as education. And all of these all encompass social determinants of health that then impact the prevalence of diabetic retinopathy risk factors, as well as screening for diabetic retinopathy and later management. So we wanted to really address all of this.

And what we found was that lower socioeconomic status, lower household income, education level, rural geography, and minority status are all associated with reduced access to diabetic retinopathy screening. And then because there's less access to screening, there are delays in diagnosis of diabetic retinopathy just due to this reduced access and that can compound risk factors that already lead to worse diabetes and visual outcomes.

So in the review, we discuss these barriers to screening. We describe new screening methods that might help improve access, which would then lend to early diagnosis of diabetic retinopathy, and then efforts to manage and treat the disease while also mitigating these disparities. There are known inequities in access to treatment as well as who is participating in clinical trials. And we know that minoritized populations are less often participating in these clinical trials and therefore, also have less access to these novel treatments.

Jessica Bard:

How did this review topic come about?

Dr Risa M. Wolf:

This review was really inspired by Dr Felicia Hill-Briggs in her diabetes care 2021 article entitled Social Determinants of Health and Diabetes, A Scientific Review, where she systematically reviewed five social determinants of health and the impact on diabetes outcomes in adults. And she focused on socioeconomic status, neighborhood and physical environment, food environment, health care, and social context, and really ended with recommendations to standardize these elements of social determinants of health and research in order to improve the generalizability of these interventions and implementation of science and clinical care. And my research team was inspired by this article because we thought it would be a great idea to look at how all of these elements of social determinants of health impact diabetic retinopathy in particular, more than just overall diabetes.

Jessica Bard:

And then I know you mentioned some of these before, but would you like to walk us through the risk factors of diabetic retinopathy?

Dr Risa M. Wolf:

Sure. So there are many risk factors for diabetic retinopathy, namely elevated hemoglobin A1C levels, which we use as a marker of glycemic control, a longer duration of diabetes, elevated albumin excretion, which is related to diabetic nephropathy, and then a higher mean diastolic blood pressure or hypertension. And some of these are also comorbidities of diabetes, but they're also considered risk factors for diabetic retinopathy.

Jessica Bard:

And can you walk us through each of the social determinants of health that you studied in this review and how they impact the prevalence of diabetic retinopathy?

Dr Risa M. Wolf:

So the few social determinants of health that we focused on were socioeconomic status. So this again relates to household income as well as insurance coverage. And we found that if you have a lower household income or Medicaid insurance that you might have less access to screening for glycemic control and an increased risk for diabetic retinopathy prevalence. Geography was another aspect that we looked at, and this also relates to access in terms of if you live in a rural community, you may not have access to get to screening or to get to care versus people who might live in a more urban environment where they have access to more health institutions and hospitals and primary care offices. Although that said, there are definitely some neighborhood environments within an urban community that also might have decreased access to health care screening. Health care access and affordability again relates to insurance coverage and the affordability of screening, attending clinical care visits, especially if you have work conflicts or are not able to take time off to do that.

Jessica Bard:

How do you believe that this review could potentially impact clinical practice going forward?

Dr Risa M. Wolf:

When we take care of patients, I think we really need to consider the whole patient. And when we think about managing their diabetes and helping them access screening, making sure they're getting the treatments that they need. And I think that all starts with really considering these social determinants of health. And if you're seeing a patient who is on public insurance and maybe from a minoritized population, you might need to go the extra mile to say, I need to make sure that they get screened and I'm going to connect them with the right place to get that done. Versus just saying, please go get this done, which may not translate to actually accomplishing the active screening. So I think we really need to consider the whole patient when we are providing clinical care.

Jessica Bard:

And what would you say is next for research on this topic?

Dr Risa M. Wolf:

So this actually goes back to what Dr Hill-Briggs stated in her review article on this is that we really need to standardize the ways that we are defining social determinants of health because if we all define them in different ways, it'll be really hard to come up with any actionable items, particularly in the research implementation science field. So, I agree that standardizing the specific elements of social determinants of health and how we define those can help us have very specific variables that we look at, and that also increases the reliability and the generalizability of the findings that we have from interventions that may be successful in a research setting.

Jessica Bard:

And the overall take-home messages from your study to sum it all up.

Dr Risa M. Wolf:

Overall, I would suggest that there are many social determinants of health that impact screening, prevalence, and the management of diabetic eye diseases more than considering just the racial and ethnic disparities that exist. And I think we really need to consider the whole person, the whole patient and their experience related to these social determinants of health. So identifying really who's at risk for diabetic retinopathy, making sure that we are helping them to access screening. And in this article, we also talk about some of the newest technologies for diabetic retinopathy screening, and this includes teleretinal network programs where you get your eye screening done at the point of care, and those images are sent in a deferred manner for interpretation by an eye care provider.

There are also the latest technology is autonomous artificial intelligence screening, which was FDA approved in 2018. It can be done also at the point of care where the patient is actually provided an immediate result of their eye exam findings. And this has actually been shown in several recent studies to improve follow-up when there is an abnormal eye exam result. So patients are actually more likely to then go for follow-up care to an eye care provider. So this may be another great way to improve screening as well as follow-up and management of diabetic eye diseases.

And then I think finally in terms of management, making sure that we have equitable access to treatments for diabetic retinopathy so that these disparities that we see in who gets access to treatment will be accessible to all in order to really improve visual outcomes for all people with diabetes.

Jessica Bard:

Well, Dr. Wolf, thank you. Is there anything else that you'd like to add today?

Dr Risa M. Wolf:

No, thank you so much for the opportunity to discuss this topic